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HX00044784 


CONDUCTION 


mil  1       AND  iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiniiiiiiiMiiiiii"""! 


INFILTRATION 
ANESTHESIA 


BY 


MENDEL   NEVIN,   D.  D.  S. 


mt\)t€\tyctMmfcxk 

CoUege  of  ^fjpsiictans  anti  ^urgeonfiJ 

Hibrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/conductioninfiltOOnevi 


CONDUCTION 


AND 


INFILTRATION 
ANESTH  ES I  A 


WITH 


\^A0v^ 


PROCAINE  TABLETS 


BY 


MENDEL    NEVIN,    D.  D.  S. 


19     19 
EDITION 


PUBLISHED     BY 

NOVOCOL    CHEMICAL    MFG.     CO,    Inc. 
BROOKLYN,    N.    Y. 


l^l^ 


FOREWORD 

The  object  of  this  hookk't  is  to  out- 
line in  a  concise  and  explicit  manner 
the  modus  operandi  of  different  injec- 
tions in  conduction  and  infiltration 
anesthesia  and  also  to  give  a  few  help- 
ful hints  as  to  the  preparation  of  the 
solution  and  sterilization  of  the  different 
instrumentarium  employed. 

The  average  practitioner  is  often 
puzzled  by  the  mass  of  literature  and 
books  written  on  the  suliject,  and  the 
different  technique  advocated  by  the 
various  writers.  It  is  therefore  our  aim 
to  select  what  we  consider  to  be  the 
simplest  and  most  practical  methods  and 
present  them  to  the   dental   profession. 


I 


CHAPTER  I 


-^  ANATOMY 

"Confidence  born  of  knowledge"  is  an  essential  element  in  master- 
ing the  technique  of  eontluction  anesthesia.  One  must  know  the 
structures  which  the  operator's  needle  may  encounter  and  the  dif- 
ferent nerves  which  he  intends  to  anesthetize.  A  few  hours  spent  in 
reviewing  the  osteology,  muscles,  blood  and  nerve  supply  of  the  head 
and  neck  will  not  only  prepare  the  practitioner  for  nerve  blocking, 
but  will  also  be  to  him  a  great  source  of  pleasure  and  gratification  in 
knowing  the  structures  of  the  field  of  his  daily  work. 

It  is  regrettable  that  space  will  not  permit  us  to  enter  into  a 
detailed  description  of  all  the  important  anatomical  structures,  but  of 
necessity  we  must  confine  ourselves  only  to  the  nerve  supply  of  the 
maxilla,  mandible,  and  the  teeth. 


TRIFACIAL    NERVE 

The  Trifacial  (fifth  cranial)  nerve  is  a  compound  nerve — being 
the  sensory  nerve  of  the  head  and  face  and  motor  nerve  of  the 
muscles  of  mastication. 

The  branches  of  the  Trifacial  nerve  are: 

1.  Ophthalmic — the  sensory  nerve  of  the  eyeball  and  sur- 
rounding structures. 

2.  Superior  Maxillary  Nerve — supplying  with  sensation  the 
upper  jaw,  gums,  teeth,  hard  and  soft  palate,  lower  eye- 
lids, upper  lip,  and  muscles  of  the  nose. 

3.  Inferior  Maxillary  Nerve — consisting  of  a  sensory  and 
a  motor  root.  The  sensory  root  supplies  with  sensation 
the  mandible,  tongue,  lower  gums,  teeth,  and  lip,  while 
the  motor  root  supplies  the  muscles  of  mastication. 

"We  will  consider  here  only  the  second  and  third  divisions  of  the 
Trifacial  nerve. 

THE  SUPERIOR  MAXILLARY  DIVISION 

The  Superior  IMaxillaiy  nerve  leaves  the  cranium  l)y  the  foramen 
rotundum  on  the  greater  wing  of  the  sphenoid  bone,  crosses  the 
spheno-maxillary  fossa,  and  then  enters  the  orbit  through  the  spheno- 
maxillary fissure.  It  then  runs  on  the  floor  of  the  orbit  in  tlie  Infra- 
orbital canal  and  is  known  as  the  Infra-orbital  nerve.  It  emerges 
on  the  face  from  the  Infra-orbital  foramen.  Before  entering  the 
Infra-orbital  canal  it  gives  off  the  Posterior  Superior  Dental  branches, 
which  enter  the  Posterior  Superior  Dental  foramina  on  the  tuberosity 

Page    Three 


of  Zygomatic  surface  of  the  Superior  Maxillary  bone,  and  supply 
the  three  upper  molar  teeth,  the  gums  and  alveolar  process  on  their 
buccal  side.  In  the  Infra-orbital  canal  the  Middle  Superior  Dental 
Branch  is  given  off,  supplying  the  bicuspid  teeth,  and  finally  just 
before  it  emerges  from  the  Infra-orbital  foramen,  the  Anterior  Su- 
perior Dental  Nerve  is  given  off,  running  in  a  special  canal  in  the 
facial  surface  of  the  Superior  Maxillary  bone  and  supplying  the 
incisor  and  cuspid  teeth,  and  also  the  gums  and  alveolar  process  and 
periosteum  on  their  labial  side. 

On  the  face  three  branches  are  given  off — palpebral,  nasal,  and 
labial — supplying  the  lower  eyelid,  the  side  of  the  nose  and  the 
upper  lip.     (Figure  1.) 

MECKEL'S    GANGLION 

In  connection  with  the  Superior  Maxillary  Nerve,  we  must  also 
consider  the  Meckel's  or  Spheno-Palatine  Ganglion.  We  have  noted 
above  that  the  anterior,  middle  and  posterior  dental  nerves  are 
supplying  the  pulps  of  the  upper  teeth,  the  gum  tissues  on  the  buccal 
side  and  the  outer  alveolar  plate.  The  inner  alveolar  plate  and  the 
gums  and  mucous  membrane  on  the  lingual  surfaces  as  well  as  the 
hard  and  soft  palates  are  supplied  by  the  nerves  given  off  from  the 
Meckel's  Ganglion. 

Meckel's  Ganglion  is  situated  in  the  Spheno-Maxillary  fossa,  near 
the  Spheno-Palatine  foramen,  just  below  the  Superior  Maxillary 
Nerve.  This  ganglion  possesses  sensory,  motor  and  sympathetic  roots, 
its  sensory  roots  being  derived  from  the  Superior  Maxillary  Nerve. 

Of  all  of  its  branches  of  distribution,  we  are  most  vitally  inter- 
ested with  the  descending  or  palatine  going  to  the  palate  and  internal 
to  the  nose.     (Figures  1  and  2 — see  pages  5  and  6.) 

ANTERIOR,  MIDDLE  AND  POSTERIOR  PALATINE  NERVES 

The  descending  or  palatine  branches  are  three  in  number — an- 
terior, middle  and  posterior.  The  anterior  palatine  nerve  passes 
through  the  posterior  palatine  foramen,  which  is  situated  V2  cm. 
above  and  posteriorly  to  the  upper  first,  second  or  third  molar  tooth 
(depending  upon  the  age  of  the  patient)  and  is  formed  by  the  junction 
of  the  superior  maxillary  bone  with  the  horizontal  plate  of  the  palate 
bone.  The  nerve  runs  in  a  groove  on  the  hard  palate  up  to  about  the 
canine  tooth,  supplying  the  gums,  mucous  membrane  of  the  hard 
palate  as  far  as  the  cuspid  tooth.  The  middle  and  posterior  palatine 
nerves  pass  through  the  accessory  and  posterior  palatine  canals 
respectively  and  supply  the  soft  palate,  tonsils,  and  uvula. 


NASOPALATINE    NERVE 

Of  the  internal  branches  we  are  mostly  interested  with  the  Naso- 
palatine nerve,  which  enters  the  nasal  fossa  through  the  naso-palatine 
foramen,  passes  to  the  roof  of  the  nose  and  then  runs  obliquely  along 

Page  Four 


^32 


Figure  1 

Trifacial    Nerve.      Light    lines   are   the    branches    running    in    bony    structures,    dark   lines    in    soft 

tissues.      (After  Sobotta.) 

Page   Five 


Ilic  scpliuii,  being  lodged  in  the  iinso-pa Inline  eaiKil  in  the  Vomer 
bone,  and  finally  enters  the  oral  cavity  through  the  anterior  palatine 
(incisor)  foramen,  supplying  the  mucous  membrane  and  the  hard 
l)alate  of  the  incisor  and  cuspid  regions  and  anastomosing  with  the 
anterior  palatine  nerve  on  the  same  side. 


INFERIOR   MAXILLARY    (MANDIBULAR)    NERVE 

The  Inferior  IMaxillary  Nerve  (Figure  1 — see  page  5)  is  the  largest 
of  tlie  three  divisions  of  the  fifth  nerve  and  the  one  which  contains  its 
motor  root.  It  leaves  the  cranium  by  the  foramen  ovale  on  the  greater 
wing  of  the  sphenoid  bone  and  immediately  upon  its  exit  divides  into 
two  trunks — anterior  and  posterior. 

The  anterior  trunk  is  the  motor  nerve  of  the  muscles  of  mastica- 
tion, supplying  the  following  muscles :  the  masseter,  temporal,  ex- 
ternal pterygoid,  and  buccinator.  The  Internal  Pterygoid  muscle 
is  supplied  by  a  branch  of  the  Inferior  Maxillary  before  its  division. 


BUCCAL  NERVE 

It  is  important  for  us  to  note  one  of  the  branches — Buccal    (or 
long    buccal).      This    nerve    runs    along    the    inner    surface    of    the 


Spheno-palatine 
ganglion 


t\  Terminal    branch  of 

>■«■  ''         naso-palatine   N. 


Anastomosis    of 
palatine   N. 


Lingual   N. 

Figure  2 

Anastomosis   of   nasopalatine   and   anterior   palatine    nerves.      Distribution   of   lingual 
nerve    in    the    mandible.       (After    Bunte    and    Moral.) 

Page   Six 


eoronoid  process  of  the  lower  jaw  and  supplies  with  sensation  the 
buccinator  muscle  and  the  mucous  membrane  lining  its  inner  surface. 
The  motor  supply  of  this  muscle  is  derived  from  the  facial  (seventh) 
nerve. 

The  posterior  trunk  of  the  inferior  maxillary  is  a  sensory  nerve, 
receiving  but  a  few  filaments  from  the  motor  root.  Of  its  three 
branches,  we  will  take  up  the  lingual  (gustatory)  and  inferior  dental. 


Figure  3 

(Sobotta)  —  (e)    lingual   nerve;    (f)    inferior 
dental    nerve;    (h)- inferior   dental    artery. 


LINGUAL    NERVE 


The  lingual  nerve  runs  for  some  distance  together  with  the  inferior 
dental.  It  then  passes  on  the  inner  side  of  the  ramus  to  the  side  of 
the  tongue  and  supplies  the  papillae,  the  anterior  two-thirds  of  the 
tongue  and  also  the  lingual  mucous  membrane  and  periosteum  of  the 
lower  teeth. 


INFERIOR    DENTAL    NERVE 


The  Inferior  Dental  Nerve  (Figures  3,  4  and  18 — see  pages  7,  8 
and  18)  passes  with  the  inferior  dental  artery  to  the  inferior  dental 
foramen.  The  nerve  runs  at  first  beneath  the  External  Pterygoid 
muscle  and  then  between  the  ramus  of  the  mandible  and  the  internal 
lateral  ligament.  Having  entered  the  inferior  dental  foramen,  it  runs 
forward  in  the  inferior  dental  canal  beneath  the  lower  teeth.  At  the 
mental  foramen  it  divides  into  two  branches — mental  and  incisor. 
From  the  inferior  dental  and  incisor  nerves  dental  branches  are  given 
off  to  supply  the  pulps  of  tlie  lower  teeth. 

Pacje   Se7'en 


M.      pteryeoideus  extermi 

N.      auriculotcmpnrali'i 

N.      auriciilo- 
-temporalis   ■ 
meatus  acustici 
externi        ~~-, 


K     temporalis  profundus  posterior    N.     fe!:iporalis  profundus  mcdius 

-'    '  N      temporalis  profundus  anterior 


Processus  mastoideu 

Rami  anastomotic!  ci  i 
n.   facial! 


naxillaris  interna 


N.     facialis 

N.      massetericus  ' 
M.     masseter 

N.      mylohyoideus'. 
N.     alveolaris  inferior 
N.      Im 

N.     buccinatorius    |  dentalis  inferior 
M.      pterygoideus  internus 

Figure  4 

(Spalteholz) 


N       mentalis 
M.n.lihula 
\1     biicriiiator 
I  dtntales  inferiorest 


MENTAL    NERVE 

The  mental  branch  emerging  from  the  mental  foramen  anastomoses 
with  its  fellow  on  the  opposite  side,  supplying  the  chin,  lower  lip,  and 
mucous  membrane  (Figure  4). 

Note  (Figure  5)  the  relation  of  the  inferior  maxillary  nerve  to 
the  inferior  maxillary  artery,  which  is  situated  posteriorly  and 
externally  to  the  nerve. 


Figure  5 


Relation   of  nerve  and  vessels  In  the   pterygo- 
mandibular space.      (Zuckerkandl.) 


Pacic   Eight 


CHAPTER  II 

STERILIZATION  AND  PREPARATION  OF  THE 

SOLUTION 

An  extraction  may  be  considered  successful  when  the  operation 
is  painlessly  performed  and  it  is  not  followed  by  any  post  operative 
complications.  One  of  the  most  frequent  causes  of  after  pain  is 
infection. 

An  extraction,  being  a  surgical  operation,  should  be  treated  as 
such,  and  no  time  or  pains  should  be  spared  in  maintaining  strict 
asepsis  during  the  operation.  It  is  true  that  the  oral  cavity  is  less 
susceptible  to  infection  than  some  other  parts  of  the  body.  Never- 
theless, there  are  a  number  of  cases  on  record  where  severe  infections 
and  even  death  followed  the  extraction  of  a  tooth.  It  is  therefore 
imperative  that  all  possible  precautions  be  exercised  in  the  steriliza- 
tion of  the  needles,  syringes  and  the  preparation  of  the  injecting 
solution. 

ISOTONIC    SOLUTIONS 

One  of  the  first  principles  we  must  bear  in  mind  is  that  the 
anesthetic  solution,  when  injected,  must  not  cause  any  disturbances 
in  the  tissue  cells.  For  this  reason  we  must  use  only  isotonic  solu- 
tions, i.  e.,  solutions  which  have  the  same  density  or  salt  constituents 
as  the  cell  contents.  The  living  cell  is  surrounded  by  a  semipermeable 
membrane.  This  membrane  will  permit  only  the  cliffusiou  of  water, 
but  not  salt  ingredients.  If,  therefore,  the  injected  fluid  is  liypertonic 
— richer  in  salt  constituents  than  the  cell  contents — the  water  from 
the  cell  will  escape  into  the  injected  solution,  and  the  cell  will  shrink. 
If,  however,  the  injected  fluid  is  deficient  in  salt  constituents,  or 
hypotonic,  the  reverse  will  take  place,  namely,  the  water  will  pene- 
trate into  the  cell  walls  gjid  the  cell  will  swell.  In  either  case  death 
of  the  living  cells  will  ensue,  causing  sloughing  and  pain. 


RINGER    SOLUTION 

An  isotonic  solution  is  best  prepared  by  dissolving  three  Ringer 
Tablets  to  an  ounce  of  distilled  water.  The  constituents  of  Ringer 
Tablets  are  as  follows: 

Sodium  Chloride 0.05     gram. 

Calcium  Chloride   0.004  gram. 

Potassium  Chloride   0.002  gram. 

Clinical  tests  have  proven  the  value  of  the  addition  of  small 
quantities  of  calcium  and  potassium  salts,  both  of  which  are  essential 

Page    Nine 


ingredients  of  the  blood  plasma  and  the  cell  contents.  The  addition 
of  minnte  quantities  of  calcium  increases  the  vital  function  of  the 
leucocytes,  thereby  also  increasing  the  resistance  to  infection. 


lOO  R^GER  TABLETS: 


Directions.- To  ottain  the  Ringer 
Solution,  dissolve  3 Ringer  Tablets 
to  I  o7..  (30  CO  of  distilled  water. 
Novocol  Chemical  Mfff.  Cc 


Figure  6 
Ringer  Tablets. 


RINGER    FLASK 

The  Ringer  stock  solution  should  be  kept  in  a  Novol  Ringer  Flask 
(Figure  7),  especially  constructed  to  protect  the  solution  from 
contamination  from  dust  and  other  foreign  particles.  It  is  provided 
with  a  ground-glass  stopper,  having  a  small  perforation.  When 
the  Ringer  solution  is  needed  the  glass  stopper  is  merely  loosened, 
not  removed,  to  admit  a  very  small  amount  of  air  necessary  for  the 
expulsion  of  the  liquid.  The  air  may  also  be  filtered  by  the  insertion 
of  sterile  cotton  in  the  glass  stopper  over  the  perforation. 


Figure  7 
Novol    Ringer   Flask. 


Page  Ten 


PREPARING  THE  SOLUTION 

When  the  patient  is  ready  for  an  extraction,  a])Out  21/0  cc.  of  the 
Ringer  stock  solution  is  poured  into  a  Novol  Porcelain  Dissolver 
(Figure  8),  and  then  boiled  over  an  alcohol  lamp  (Figure  9),  after 
which  two  Novol  Procaine-Suprarenal  Extract  Tablets  No.  1  (Dental) 
are  added. 


The  solution  is  then  again  brought  to  the  boiling  point  for  but  a 
few  moments.  Prolonged  boiling  after  the  Novol  Procaine-Suprarenal 
Extract  Tablets  have  been  added  should  be  avoided  on  account  of 
the  possibility  of  injury  to  the  chemical  composition  of  the  Suprarenal 
Extract. 


Boiling    the    Ringer 
Solution. 


During  the  process  of  manufacture  the  Novol  Procaine  Tablets 
are  not  touched  by  human  hands.  To  safeguard  them  from  con- 
tamination, it  is  also  important  that  they  are  not  handled  with  the 
fingers  liy  the  operator.  Sterile  pliers  may  be  used  for  this  purpose. 
A  still  l)etter  method  is  to  gently  turn  the  tube  until  the  required 
rtumber  of  tablets  drop  into  the  dissolving  cup.  A  little  practice  will 
enable  the  operator  to  do  this  without  difficulty. 

Page    Eleven 


The  unused  portion  of  the  solution  should  be  covered  with  the 
glass  cover  provided  with  the  Novol  Porcelain  Dissolver  to  protect 
it  from  contamination  (Figure  10). 


The  solution  is  now  drawn  up  into. the  syringe  through  the  hypo- 
dermic needle,  previously  sterilized.  By  this  time  the  solution  will 
be  reduced  to  the  body  temperature,  which  is  the  most  suitable  for 
injection. 


PERCENTAGE   SOLUTIONS 

The  Novol  Procaine-Suprarenal  Extract  Tablets  No.  1  (Dental) 
contain  each 

Procaine  0.02  gram 

Suprarenal  Extract  0.000045  gram 

so  that  by  dissolving  two  of  these  tablets  in  the  manner  indicated  an 
approximately  2%  Procaine  solution  and  0.000045  gram  Suprarenal 
Extract  to  1  cc.  will  be  obtained. 

We  advocate  2i/o  cc.  to  allow  for  evaporation  in  boiling,  and  also 
to  be  assured  of  a  syringeful  (2  cc),  the  average  quantity  necessary 
for  an  extraction. 

If  a  smaller  percentage  of  Suprarenal  Extract  is  desired,  Novol 
Procaine  Tablets  No.  2  should  be  used  instead,  as  they  have  about 
half  the  amount  of  Suprarenal  Extract.     These  tablets  contain  each 

Procaine  0.02  gram 

Suprarenal  Extract  0.00002  gram 

and  when  dissolved  in  2  cc.  Ringer  solution  will  yield  a  2%  Procaine 
solution  and  0.00002  gram  Suprarenal  Extract  to  each  cc. 

Novol  Procaine  Tablets  No.  4  have  no  Suprarenal  Extract,  but 
only  0.05  gram   Procaine. 

Some  operators  prefer  to  combine  one  Novol  Tablet  No.  1  with 
one  Novol  Tablet  No.  4  in  31/2  cc.  Ringer  solution,  obtaining  a  2% 
Procaine  solution   and  Suprarenal  Extract  0.000015  gram  to  each  cc. 

Page   Twelve 


CHAPTER  III 


CARE   OF   SYRINGES   AND   NEEDLES 

The  care  of  the  syringes  and  needles  is  just  as  essential  as  the 
preparation  of  the  solution. 


NOVOL  PERFECTO  SYRINGE 

The  selection  of  the  proper  syringe  has  always  been  the  concern 
of  the  dental  surgeon.  An  ideal  syringe  must  be  non-leakable  and 
washerless.  The  particles  of  the  felt  washers  not  only  clog  the  lumen 
of  the  needles,  but  may  sometimes  cause  serious  complications  when 


Figure  11 
Novol    Perfecto  Syringe. 


Figure  12 

Parts  of   Novol    Perfecto   Syringe 
adjusted   on    metal   plate. 

Page     Thirteen 


injected  iiilo  the  1  issue.  The  syriutic  must  Jilso  not  he  too  euuiher- 
sonie,  and  at  tlie  same  time  sliould  he  easily  takeu  apart  for  cleaning 
and  sterilization. 

All  these  features  have  been  taken  into  consideration  in  construct- 
ing the  Novel  Perfecto  Syringe  (Figure  11 — see  page  VA). 

The  Novol  Perfecto  Syringe  is  especially  constructed  for  the  dental 
surgeon.  It  is  devoid  of  washers  and  built  of  glass  and  metal  only. 
The  metal  plunger  and  end  plug  fit  accurately  and  snugly  to  the 
ground-glass  barrel.  It  holds  35  minims  (a  little  over  2  ce.)  and  is 
tested  to  about  250  pounds  continuous  pressure,  so  that  it  may  be 
used  efficaciously  without  regurgitation  of  the  fluid,  in  conduction  as 
well  as  in  infiltration  anesthesia,  an  imj^ortant  feature  to  the  dental 
surgeon.  It  is  easily  taken  apart  for  sterilization  purposes,  as  shown 
on  the  illustration. 

A  word  of  warning  is  here  perhaj^s  necessary.  In  sterilizing  the 
Novol  Perfecto  Syringe  it  should  never  be  boiled  or  very  hot  water 
drawn  into  it.  unless  it  is  taken  apart,  as  otherwise  the  different 
degrees  of  expansion  of  the  glass  and  metal  under  the  influence  of 
heat  may  cause  the  glass  barrel  to  break. 

All  the  parts  of  the  Novol  Perfecto  Syringe,  together  with  the 
needles,  are  adjusted  on  a  metal  plate  (Figure  12 — see  page  13),  so 
that  they  may  all  he  sul)merged  and  removed  at  one  time  from  the 
sterilizer. 

The  metal  box,  in  which  the  Novol  Syringe  together  with  all  the 
attachments  and  needles  are  packed,  may  be  very  conveniently  used 
at  the  same  time  as  a  sterilizer,  as  shown  in  illustration  (Figure  11 — 
see  page  13). 

All  the  parts  of  the  Novol  syringe,  as  well  as  the  attachments  and 
hypodermic  needles,  are  adjusted  on  the  metal  plate  and  submerged 
into  the  metal  case,  half  filled  with  water.  The  case  is  then  placed  on 
the  stand  (Figure  13 — see  page  15),  and  the  water  brought  to  boiling 
by  either  a  bunsen  burner  flame  or  the  small  can  of  solidified  alcohol. 

The  syringe  should  be  thoroughly  cleaned  and  sterilized  every 
morning,  and  then  submerged  into  a  solution  containing  70%  alcohol 
and  30%  glycerine. 

If  steel  needles  are  used  they  should  be  sterilized  by  boiling  before 
each  extraction. 

Platinum-irridium  needles  may  be  sterilized  by  subjecting  them 
to  an  alcohol  or  gas  flame. 

Only  two  size  needles  are  necessary  in  conduction  anesthesia — 
the  42  mm.  (1%")  and  25  mm.  (1")  with  the  hubs  attached  or  else 
mounted  on  the  long  or  short  hub  (Schimmel  type). 

Needles  should  be  dried  after  each  case  by  drawing  through  them 
absolute  alcohol  and  blowing  out  with  a  hot-air  syringe,  after  which 
a  thin  wire  is  introduced  into  their  lumen. 

It  is  a  good  policy  to  discard  steel  needles  after  they  have  been 
used  a  number  of  times,  as  prolonged  use  may  cause  them  to  rust 
and  break. 

Page  Fourteen 


Before  using  the  syringe  or  needles  all  traces  of  alcohol  should  be 
removed  by  drawing  warm  water  through  the  syringe  several  times. 
The  injection  of  alcohol  is  very  irritating  and  may  also  cause  undue 
prolongation  of  the  anesthesia. 


DISINFECTION  OF  THE  FIELD  OF  OPERATION 

One  missing  link  in  the  cycle  of  all  the  antiseptic  precautions 
necessary  to  successful  local  injection  is  often  sufficient  to  cause  post- 
operative complications,  such  as  edema,  pain,  and  sloughing.  The 
disinfection  of  the  field  of  operation  is  just  as  important  as  the 
sterilization  of  the  instruments  and  the  preparation  of  the  solution. 

Tincture  of  iodine  and  tincture  of  aconite,  e(iual  parts,  have  been 
found  to  be  ideal  in  the  sterilization  of  the  mucosa  in  surgery,  and  are 
especially  advantageous  around  the  oral  cavity.  The  point  of  injec- 
tion is  painted  with  the  aconite  and  iodine  solution.  The  iodine  has 
a  deep  penetrating  power,  hardening  the  mucosa  and  preventing  the 
bacteria  from  penetrating  into  the  puncture.  The  combination  at  the 
same  time  acts  as  an  analgesic,  counteracting  the  slight  pain  caused 
by  the  insertion  of  the  needle  into  the  mucous  membrane. 


Figure  13 

Novol    Perfecto   Syringe   in    metal    box   in    process 
of    sterilization. 


Page    Fifteen 


CHAPTER  IV 


CONDUCTION  ANESTHESIA 

The  most  iinportant  and  perhaps  most  difficult  of  all  the  injec- 
tions in  nerve  blocking  is  the  mandibular. 

Every  dental  practitioner  who  has  attempted  to  anesthetize  a 
lower  molar  tooth  with  an  ordinaiy  subperiosteal  injection  knows 
the  great  difficulties  attending  this  procedure.  The  reason  is  quite 
obvious.  A  glance  at  the  mandible  will  show  us  the  great  density  and 
thickness  of  the  alveolar  plates  in  that  region,  so  that  diffusion  of 
the  anesthetic  solution  into  the  alveolus  is  very  difficult  and  some- 
times impossible.  But  with  one  mandibular  injection,  however,  it  is 
possible  to  anesthetize  not  only  the  molars,  but  almost  all  the  teeth  to 
the  median  line  on  that  side. 

The  results  then  obtained  by  this  injection  will  more  than  repay 
the  time  and  patience  expended  in  mastering  its  technique. 


r 

a 

m  ' 

H     %, 

w.  ^^_ 

~i  i  .. 

't  \ 

FM. 

"* 

■-    c 

d  '    •             1 

MANDIBULAR  INJECTION 

Besides  the  nerve  supply  of  the 
mandible  which  we  have  described 
on  the  first  few  pages  of  this  book- 
let, we  must  also  consider  other  ana- 


f'lgUI  I 


Figure  14 

(a)      External      oblique 

Internal    oblique    line. 

and    Moral.) 

Page  Sixteen 


line;      (b) 
(Bunte 


(a)  External  oblique  line;  (b)  In- 
ternal oblique  line;  (c)  position  of 
the  needle;  (d)  occlusal  plane;  the 
punctuated  line  forms  the  boundary 
of   the    mandibular   sulcus.      (Seidel.) 


Figure  16 

(1)  Palpating  Externa!  oblique  line;  (2)  Palpating  Retromolar  fossa;  (3) 
Palpating  Internal  oblique  line;  (4)  Insertion  of  the  needle  and  injecting  for  the 
lingual  nerve;  (5)  Placing  the  syringe  between  the  two  bicuspids  on  the  opposite 
side;    (6)    Injection    into    the    mandibular   sulcus. 


m 


toniicfil  structures  of  the  lower  maxilhi   in  oi-der  to  uuister  the  land- 
marks for  this  injection. 

Figure  14 — see  page  16 — shows  distinctly  on  the  external  surface 
of  the  mandible  a  ridge  running  at  first  horizontally,  but  then  inclin- 
ing upward  and  continuing  with  the  anterior  border  of  the  ascending 
ramus.  This  ridge  is  known  as  the  external  oblique  line.  On  the 
internal  surface  (Figure  15 — see  page  16)  we  have  the  mylo-hyoid 
ridge  or  the  internal  oblique  line,  which  is  not  quite  as  distinct,  but 
being  especially  prominent  in  the  region  of  the  molar  teeth.  These 
two  ridges,  with  the  last  molar  as  the  base,  form  the  retromolar 
triangle,  while  the  groove  within  this  ti'iangle  is  known  as  the 
retromolar  fossa. 

On  the  internal  surface  of  the  ascending  ramus  we  note  in  the 
center  the  Inferior  Dental  Canal,  protected  anteriorly  by  a  spicule 
of  bone — the  lingula,  which  gives  attachment  to  the  internal  lateral 
ligament.  Below  is  a  rough  surface  for  the  attachment  of  the  Internal 
Pterygoid  muscle  (Figure  15 — see  page  16),  while  the  coronoid  and 
condyloid  processes  give  attachments  to  the  Temporal  and  External 
Pterygoid  muscles  respectively.  The  space  l)etween  these  muscles  is 
devoid  of  any  muscle  attachment  and  is  called  the  pterygo-mandibular 
space.  Posteriorly  to  the  mandilmlar  foramen  is  a  depression  known 
as  sulcus  manclihularis,  where  the  mandibular  injection  is  made. 

The  techni(jue  of  this  in- 
jection is  as  follows: 

On  the  right  side.  Place 
your  left  index  finger  in  the 
patient's  mouth,  buccally  to 
the  lower  teeth,  pushing  the 
cheek  outward,  and  moving  the 
finger  upward,  until  you  strike 
the  external  oblique  line  (Fig- 
ure 16-1 — see  page  17).  Now 
place  the  palm  of  your  finger 
over  the  occlusal  surface  of  the 


Figure  17 

(b)   Area  supplied   by  Long   Buccal   Nerve; 
(m)  mental  foramen.     (Fischer.) 

Page  Eighteen 


Figure  IS 

Cross  section  through  the  ascending 
ramus  of  the  jaw  parallel  to  the  biting 
surface  of  the  teeth  of  the  lower  jaw. 
(a)  Mandible;  (b)  masseter  muscle;  (c) 
internal  pterygoid  muscle;  (d)  inferior 
dental  nerve;  (e)  pharynx;  (f)  tonsil; 
(g)  lingual  nerve;  (h)  position  of 
needle;  (i)  floor  of  the  mouth;  (k)  ves- 
tibulum  oris;  (j)  buccinator  muscle. 
(Braun.) 


Figure  19 

Injection     at     the     lingula,     showing     the 
position    of   the   syringe.      (Braun.) 


lower  teeth  and  tiiid  witli  tlu'  ball 
of  your  finger  the  depression  pos- 
teriorly and  externally  to  the  last 
molar — the  retromolar  fossa  (Fig- 
ure 16-2 — see  page  17).  Next  turn 
the  palm  of  your  finger  outwardly 
and  with  your  finger  nail  palpate 
the  internal  obliifue  line,  resting 
the  radial  side  of  your  index  finger 
on  the  occlusal  surfaces  of  the- 
teeth    (Figure   16-3 — see   page    17) 


Figure  20 

(a)  Tendo,  muse,  tensoris  veli  palatini; 
(b)  bucca;  (c)  muse,  buccinatorius;  (d) 
raphe  pterygo-mandibularis;  (e)  muse, 
cephalo-pharyngeus;  (f)  muse,  pharyngo- 
palatinus;  (g)  muse,  glosso-palatinus; 
(h)     glandulae    molares.       (Sobotta.) 


Xow,  moving  the  finger  nail 
slightly  outwardly  to  expose  the  internal  oblique  line,  the  area  is 
painted  with  aconite  and  iodine.  The  syringe  is  held  in  the  right 
hand  in  a  penlike  manner  and  the  needle  is  inserted  into  the  soft 
tissues  covering  the  internal  obli(pie  line,  using  the  center  of  the 
finger  nail  as  a  guide,  or  1  -cm.  above  the  occlusal  surfaces  of  the 
lower  teeth  (Figure  16-4 — see  page  17).  Push  the  needle  slightly 
inw^ard,  holding  the  syringe  parallel  with  the  hody  of  the  mandible 
and  inject  about  three  drops  to'  anesthetize  the  lingual  nerve,  which, 
as  we  have  stated,  supplies  the  lingual  mucous  membrane  and  perios- 
teum of  the  lower  alveolar  process.  The  syringe  is  then  placed  on 
the  opposite  side  between  the  two  bicuspid  teeth  or  between  the 
canine  and  first  bicuspid,  depending  upon  the  angle  formed  by  the 
ascending  ramus  (Figure  16-5 — see  page  17)  and  the  needle  is  slowly 
advanced  posteriorly,  keeping  all  the  time  in  contact  with  the  internal 
surface  of  the  ascending  ranuis,  until  about  one  inch  of  the  needle 
has  disappeared,  when  the  contents  of  the  syringe  are  slowly  injected 
(Figure  16-6 — see  page  17).  If  the  proper  technique  is  carried  out 
the  solution  will  be  deposited  in  the  upper  part  of  the  mandibular 
sulcus.  Complete  anesthesia  to  almost  the  lateral  incisor  will  follow 
in  from  ten  to  twentv  minutes. 


Page    Nineteen 


The  same  technique  is  carried  out  on  the  left  side,  with  the  one 
exception  that  the  right  index  finger  is  used  in  palpating,  while  the 
syringe  is  held  with  the  left  hand.  Some  operators,  however,  prefer, 
while  injecting  on  the  left  side,  to  use  the  left  index  finger  as  a  guide, 
injecting  at  the  same  time  with  the  right  hand. 

The  anesthesia  will  manifest  itself  by  a  peculiar  sensation  on  the 
median  line  of  the  lower  lip  or  in  the  cuspid  region.  The  patient 
will  also  complain  of  a  numbness  of  the  tongue  and  lower  jaw.  It  is 
always  desirable  to  test  the  mucous  membrane  of  the  tooth  to  be 


Figure  21 
Mental    Injection. 


extracted,  both  lingually  and  buccally,  by  compressing  the  gingiva 
with  a  pair  of  sterile  pliers  or  sharp  instrument.  In  a  number  of 
cases  there  will  be  sensation  only  in  the  buccal  side,  indicating  that 
the  long  buccal  nerve  which  supplies  the  Buccinator  muscle  with 
sensation  must  be  anesthetized  separately.  This  is  easily  accomplished 
by  infiltrating  with  about  0.5  cc.  of  the  solution  the  buccal  mucous 
membrane  of  the  tooth  to  be  extracted.  In  infected  cases  the  adjoin- 
ing healthy  parts  of  the  Buccinator  muscle  may  be  anesthetized  with 
good  effect  (Figure  17 — see  page  18). 

Page   Twenty 


MENTAL    INJECTION 

By  a  mental  injection  we  may  anesthetize  the  bicuspids,  cuspid, 
and  sometimes  the  lateral  incisor.  If  a  mandibular  injection  has  been 
given  and  an  operation  on  the  two  incisors  and  cuspid  teeth  is  con- 
templated, it  is  also  necessary  to  give  an  opposite  mental  injection, 
desensitizing  the  anastomosing  filaments  from  the  opposite  mental 
nerve. 

The  technique  is  as  follows : 

Palpate  with  the  index  finger  the  mental  foramen,  which  is  gen- 
erally situated  below  and  between  the  two  bicuspid  teeth.     Retracting 


Figure  22 
Tuberosity   Injection. 


the  lip  with  the  thumb,  insert  the  needle  into  the  mucous  fold,  between 
the  two  bicuspid  teeth,  and  proceed  do\\Tiward  and  slightly  backward, 
injecting  slowly  until  the  injecting  fluid  is  felt  by  the  palpating 
finger.     Inject  about  1.5  cc.   (Figure  21.) 

Since  mandibular  injections  give  such  perfect  results,  mental 
anesthesia  is  seldom  indicated.  One  mandibular  injection  will  anes- 
thetize all  the  molars,  bicuspids,  and  sometimes  the  cuspid  on  that 
side;  while  two  mandibular  injections — one  on  either  side — will 
anesthetize  the  entire  lower  arch. 

Page    Twenty-one 


Figuie  23 
Posterior    Palatine    Injection. 


TUBEROSITY  INJECTION 

It  is  unfortunate  that  up  to  the  present  time  a  method  has  not 
as  yet  been  devised  where  by  one  or  two  injections  all  the  teeth 
of  the  Superior  Maxilla  on  either  side  could  be  anesthetized  similarly 
to  the  mandibular  injection.  Some  research  workers  advocate  various 
methods  of  blocking  the  Superior  Maxillary  Nerve  in  toto,  but  only 
with  partial  success.  We  shall  speak  of  these  later.  The  author 
himself  is  at  present  engaged  in  experimentation  with  some  of  these 
injections,  but  his  conclusions  as  to  their  absolute  safety  and  efficacy 
are  not  as  yet  final,  nor  do  his  clinical  data  so  far  warrant  advocating 
their  adoption. 

The  upper  three  molar  teeth  are  supplied  by  the  posterior  superior 
dental  nerves,  branches  of  the  Superior  Maxillary,  given  off  in  the 
Spheno-Maxillary  fossa  and  entering  the  Zygomatic  surface  of  the 
Superior   IVIaxillary   bone    at    the    posterior    superior    dental    canals. 

To  anesthetize  the  upper  molars,  insert  the  needle  into  the  reflec- 
tion of  the  mucous  membrane  of  the  distal  third  of  the  second  molar, 
having  previously  instructed  the  patient  to  partly  close  his  mouth,  in 
order  to  avoid  the  coronoid  process  of  the  ramus.  Proceed  then  with 
the  needle  at  an  angle  of  about  45  degrees,  in  the  direction  of  the 
root  apex  of  the  third  molar,  slowly  injecting  all  the  time,  until  about 

Page  Twenty-tzvo 


2  cm.  (1")  of  the,  needle  has  disappeared,  when  the  contents  of  the 
syringe  are  deposited  (about  2  cc.)-  In  cases  where  the  third  and 
second  molars  have  not  as  yet  erupted  the  tooth  preceding  the  last  one 
is  always  used  as  a  guide.  Anesthesia  occurs  from  live  to  ten  minutes, 
lasting  an  hour  or  longer  (Figure  22 — see  page  21). 

The  nnicous  membrane  and  alveolar  process  on  the  palatal  side 
of  the  upper  molars  are  innervated  by  the  anterior  palatine  nerve, 
passing  through  the  posterior  palatine  foramen,  and  it  is  therefore 
necessary  to  anesthetize  this  branch  in  case  an  extraction  or  operation 
involving  these  structures  is  contemplated.  The  zygomatic  injection 
alone  will  suffice  in  cavity  preparation  and  extirpation  of  pulps. 

POSTERIOR  PALATINE  INJECTION 

The  needle  is  inserted  into  the  mucous  membrane  on  the  palatine 
side  posteriorly  to  the  second  molar  (or  first  or  second,  depending 
upon  the  age  of  the  patient)  %  cm.  above  the  gum  margin  and 
advanced  parallel  with  the  alveolus  in  a  backward  direction  toward 


Figure  24 
Infra-orbital    Injection. 


Page     Twenty-three 


Figure  25 
Anterior    Palatine    Injection. 

the  apex  of  the  third  molar  until  the  foramen  is  reached,  where  about 
10  minims  of  the  solution  are  injected.  Anesthesia  on  the  palatal  side 
of  the  molars  and  bicuspids  will  follow  almost  immediately  (Figure 
23 — see  page  22). 

Care  should  be  taken  not  to  direct  the  needle  too  far  posteriorly, 
as  the  middle  and  posterior  palatine  nerves,  which  supply  the  soft 
palate  and  the  uvula  and  which  pass  through  the  accessory  palatine 
canals,  may  also  be  anesthetized,  causing  the  patient  a  disagreeable 
gagging  sensation. 

INFRA-ORBITAL    INJECTION 

The  central  and  lateral  incisors  and  cuspid  teeth  are  innervated 
by  the  anterior  superior  dental  nerve,  which  is  given  off  the  Infra- 
orbital nerve  just  before  it  emerges  from  the  infra-orbital  foramen. 

The  technique  of  the  injection  is  as  follows: 

An  imaginary  line  is  drawn  passing  through  the  pupil  of  the 
patient's  eye  and  the  long  axis  of  the  second  bicuspid  tooth.  The 
infra-orbital  foramen  is  then  palpated  with  the  tip  of  the  index  finger. 
The  foramen  wall  almost  invariably  be  found  on  this  imaginary  line 
about  0.5  cm.  below  the  infra-orbital  ridge.  With  the  thumb  the  lip  is 
retracted  and  the  needle  inserted  above  the  apex  of  the  second  bicuspid 
into  the  mucous  fold  as  high  as  the  reflection  of  the  mucous  membrane 

Page   Twenty-four 


will  permit.  Following  the  imaginary  line  toAvard  the  infra-orbital 
foramen,  the  needle  is  advanced,  keeping  it  away  from  the  bone,  else 
the  concavity  of  the  canine  fossa  will  retard  the  progress  of  the  needle. 
The  solution  is  slowly  injected  while  the  needle  is  being  advanced 
until  the  expulsion  of  the  solution  is  being  felt  by  the  compressing 
tip  of  the  index  finger,  when  about  1.5  cc.  of  the  solution  is  deposited. 
Anesthesia  in  the  central,  lateral  and  cuspid  teeth  of  the  side  injected 
will  follow  in  from  five  to  ten  minutes  (Figure  24 — see  page  23). 

Lingually,  however,  the  mucous  membrane,  alveolar  process  and 
periosteum  are  supplied  by  the  naso-palatine  nerve  which  emerges 
from  the  incisive  (anterior  palatine)  foramen.  This  nerve  should  be 
blocked  for  an  extraction  or  an  operation  involving  the  parts  which 
this  nerve  innervates. 


INCISIVE    INJECTION 

This  may  be  easily  accomplished  by  inserting  the  needle  lingually 
into  the  papillae,  between  the  two  upper  central  incisors,  and  pushing 
it  upward  to  the  incisive  foramen.  About  five  or  six  drops  are  suiTi- 
cient  to  produce  anesthesia  of  the  gum  tissue  and  alveolar  process 
and  periosteum  on  the  lingual  side.  The  insertion  of  the  needle  for 
this  injection  is  cpiite  painful  on  account  of  the  extreme  sensitiveness 


Fignre  26 
Injection    for    Bicuspid    Anesthesia. 


Page    Twenty-five 


of  the  papillae.  Tliis  is  easily  overcome  by  inserting  the  needle  later- 
ally to  the  papillae  and  then  advancing  toward  the  large  incisive 
foramen  (Figure  25 — see  page  24). 


NERVE  BLOCKING  FOR  THE  BICUSPID  TEETH 

A  tuberosity  injection  will  sometimes  anesthetize  the  second 
bicuspid  or  the  first  bicuspid  nuiy  sometimes  be  anesthetized  by  an 
infra-orbital  injection.  On  the  other  hand,  it  happens  quite  frequently 
that  a  tuberosity  injection  will  fail  to  completely  desensitize  the  first 
molar  tooth.  These  phenomena  appear  to  be  due  to  the  various 
methods  of  innervation  of  the  bicuspid  teeth  as  advocated  by  different 
authorities. 

Gray  describes  anastomosis  of  the  middle  superior  dental  branch 
with  the  posterior  superior  dental  forming  the  Ganglion  of  Valentine 
and  also  with  the  anterior  superior  dental  forming  the  Ganglion  of 
Bochdaleck,  neither  of  which  is  probably  a  true  ganglion. 

From  the  above  description  it  is  evident  why  we  often  fail  to 
obtain  anesthesia  in  the  first  molar  tooth  with  a  tuberosity  injection, 
as  sensation  is  conducted  by  the  anastomosis  of  the  middle  superior 
dental  branch. 

Other  authorities  maintain  that  the  middle  superior  dental  branch 
is  given  off  together  with  the  posterior  superior  dental  and  enters  the 
body  of  the  Superior  Maxilla  through  separate  canals  situated 
anteriorly  to  the  posterior  dental  canals,  which  fact  would  account 
for  the  bicuspid  anesthesia  we  sometimes  obtain  by  a  tuberosity 
injection. 

Again  this  branch  (middle  superior  dental)  may  be  absent  alto- 
gether, the  bicuspid  teeth  being  supplied  by  the  anterior  superior 
dental  nerve,  or  else  it  may  be  a  part  of  the  anterior  superior  dental 
nerve. 

From  all  of  these  descriptions  it  is  safe  to  suppose,  however,  that 
most  frequentlj^  the  bicuspid  teeth  derive  their  nerve  supply  from 
the  middle  superior  dental  branch,  which  is  given  off  somewhere  in 
the  infra-orbital  canal.  This  accounts  for  the  difficulty  in  reaching 
and  blocking  this  nerve  with  the  hypodermic  needle. 


INJECTION   INTO  SPHENO-MAXILLARY   FOSSA 

Dr.  Arthur  E.  Smith  advocates  an  injection  into  the  Spheno- 
Maxillary  fossa.  By  this  injection  not  only  the  bicuspids  but 
also  the  molars  and  anterior  teeth  on  that  side  could  be  anesthe- 
tized. The  solution  will  also  reach  Meckel's  Ganglion,  since  it  is 
located  below  the  Superior  Maxillary  nerve,  thus  obviating  the  neces- 
sity of  blocking  the  anterior  palatine  and  naso-palatine  nerves. 

The  needle  employed  for  this  injection  is  36  mm.  long,  24  gauge, 
which  is  mounted  on  a  curved  attachment  with  an  extension  arm. 
The  needle  is  inserted  laterally  to  the  third  molar,  keeping  it  in  con- 
tact with  the  Zygomatic  surface  of  the  Superior  Maxillary  bone  and 

Page   Twenty-six 


moved  upward  and  inward  until  tlie  entire  length  of  the  needle  is 
inserted.  About  2i/)  or  'S  cc.  are  injected,  and  anesthesia  will  follow  in 
from  five  to  fifteen  minutes. 

This  injection,  if  successful,  is  invaluable  in  operations  involving 
the  Antrum  of  Highmore,  or  large  areas  of  bone  and  also  in  cases 
when  it  becomes  necessary  to  extract  a  number  of  teeth  or  roots  at 
one  sitting. 

BICUSPID  ANESTHESIA 

The  writer  has  ])een  lately  experimenting  with  an  injection  which, 
in  his  opinion,  promises  to  be  of  great  value  in  conduction  anesthesia. 
By  this  injection  the  infra-orbital  nerve  is  blocked,  just  prior  to  its 
entrance  into  the  infra-orbital  canal. 

The  examination  of  the  Spheno-Maxillary  and  Zygomatic  fossae 
(Figure  26 — see  page  25)  and  their  relation  will  reveal  to  us  the 
course  of  the  second  division  of  the  Trifacial  nerve  up  to  the  time  when 
it  enters  the  infra-orbital  canal  and  is  then  known  as  the  infra-orbital 
nerve.  It  will  be  noted  that  the  infra-orbital  nerve  passes  through  the 
outer  third  of  the  Spheno-Maxillary  fissure,  where  it  enters  the  canal. 
By  blocking  the  nerve  at  this  point  we  anesthetize  not  only  the 
posterior  superior  dental,  but  the  middle  superior  branch  and  quite 
frequently  the  anterior  superior  dental  nerve. 

For  this  injection  a  42  mm.  23  gauge  platinum  irridium  needle  is 
used,  curved  in  the  manner  illustrated  (Figure  26 — see  page  25). 
The  malar  process  of  the  Superior  Maxillary  bone  is  at  first  located 
and  then  the  needle  inserted  at  the  mucous  fold  above  the  apex  of  the 
second  molar  tooth,  with  the  concavity  of  the  needle  anteriorly.  The 
needle  is  then  advanced,  keeping  it  in  contact  with  the  posterior  sur- 
face of  the  malar  process  of  the  Superior  jMaxillary  bone  until  the 
entire  length  of  the  needle  disappears,  when  about  2  cc.  of  the  solution 
is  deposited.  The  writer  has  found  this  injection  to  be  successful 
in  about  60%  of  the  cases  for  olitaining  anesthesia  in  the  bicuspids 
and  molar  teeth. 

The  best  method  of  anesthetizing  the  bicuspid  teeth,  however,  in 
the  absence  of  infection,  is  bv  infiltration. 


Page    Tzventy-seven 


CHAPTER  V 


INFILTRATION    ANESTHESIA 

By  infiltration  anesthesia  we  endeavor  to  anesthetize  the  peripheral 
filaments  of  the  Trifacial  nerve  by  injecting  the  anesthetic  either 
under  the  mucous  membrane  or  the  periosteum  above  the  tooth  or 
teeth  we  are  to  operate.  The  anesthetic  solution  by  infiltrating  the 
cancellous  structure  of  the  alveolar  process  reaches  the  terminal  nerve 
fibres  and  anesthetizes  them.  This  method  of  anesthesia  may  then 
be  subdivided  into  suhmncous  and  subperiosteal.  To  be  successful 
the  anesthetic  should  be  injected  under  the  periosteum.  This  requires 
considerable  pressure  on  account  of  the  tensity  and  firmness  of  this 
structure. 

The  same  antiseptic  precautions  should  be  exercised  in  infiltration 
anesthesia  as  are  in  nerve  blocking. 

A  25  mm.  (one  inch)  needle  should  be  employed,  platinum-irridium 
preferably. 

The  needle  is  inserted  buecally  through  the  periosteum,  mid- 
way between  the  gingiva  and  the  apex  of  the  tooth  to  be  ex- 
tracted, with  the  orifice  of  the  needle  pointing  toward  the  bone. 
The  needle  is  then  moved  along  the  bone,  injecting  slowly,  until  the 
apex  of  the  tooth  is  reached  when  about  1.5  ce.  of  the  solution  is 
deposited.  The  same  procedure  is  repeated  on  the  lingual  side, 
depositing  the  balance  of  the  solution  remaining  in  the  syringe 
(about  0.5  cc). 

Single  teeth  may  be  extracted  with  one  buccal  and  one  palatal 
injection.    Repeated  punctures  of  the  mucosa  should  be  avoided. 

INFILTRATION  ANESTHESIA  IN  UPPER  TEETH 

Frequently,  in  infiltration  anesthesia,  a  number  of  teeth  may  be 
anesthetized  wdth  but  one  buccal  puncture,  particularly  when  the 
bicuspids  and  molars  of  the  Superior  Maxilla  are  to  be  extracted. 
The  needle  (42  mm.  long)  is  inserted  at  the  level  of  the  root  apex  of 
the  canine  tooth  where  the  solution  is  gradually  discharged  in  order 
to  anesthetize  this  tooth.  If  the  bicuspids  and  molars  are  to  be 
anesthetized,  the  needle  is  then  slowly  advanced  over  the  apices  of 
these  teeth  and  the  solution  slowly  injected  over  each  tooth.  With  the 
long  1%"  needle  it  is  possible  to  reach  the  root  apices  of  the  first 
and  sometimes  the  second  molar.  If  it  is  also  necessary  to  anesthetize 
the  anterior  teeth,  the  syringe  is  refilled  and  the  needle  inserted  again 
into  the  same  puncture  over  the  canine  tooth  and  the  needle  advanced 
toward  the  apices  of  the  lateral  and  central  incisor  teeth,  anesthetizing 
each  tooth  as  the  needle  advances. 

Palatally,  a  posterior  or  anterior  palatine  or  both  injections  are 
given,  depending  upon  the  teeth  to  be  extracted. 

Page   Tiventy-eight  . 


INFILTRATION   ANESTHESIA   IN   THE   LOWER  ANTERIOR 

TEETH 

In  the  mandible,  by  the  infiltration  method,  it  is  possible  to 
anesthetize  the  six  anterior  teeth  in  the  following  manner: 

Insert  the  needle  labially  between  the  two  lower  central  incisor 
teeth,  at  their  apex  level.  Then  proceed  on  to  the  right,  injecting 
slowly  until  the  incisive  fossa  is  reached,  where  about  1  cc.  of  the 
solution  is  deposited.  This  fossa  is  located  below  the  apices  of  the 
lateral  incisor  and  canine  tooth.  The  needle  is  drawn  back  to  the 
median  line  and,  without  withdrawing  it  entirely  from  the  tissues,  it 
is  directed  to  the  incisive  fossa  on  the  opposite  side,  where  another 
1  cc.  of  the  solution  is  deposited. 

Lingually,  about  14  cc.  is  injected  behind  each  central  incisor 
and  also  between  the  canine  and  first  bicuspid  teeth.  Satisfactory 
anesthesia  will  be  obtained  in  this  manner  for  the  incisors  and 
cuspid  teeth. 


CHAPTER  VI 


POST-OPERATIVE    SEQUELAE 

One  of  the  most  fre(|uent  causes  of  after  pain  is  infection,  which 
may  be  due  to  non-sterile  solution,  syringe  or  needle.  A  sterile  needle 
may  also  be  reinfected  by  coming  in  contact  with  the  mucous  mem- 
brane or  fluids  of  the  mouth.  Care  should  be  taken  before  and  during 
the  injection  not  to  contaminate  the  needle  in  this  manner. 

Pain  after  extraction  may  be  also  caused  by  a  septic  condition 
alreadj^  existing  or  else  by  the  wound  being  infected  during  or 
subsequent  to  the  extraction.  The  sockets  of  infected  teeth  should 
be  thoroughly  curetted  after  the  extraction. 

Deteriorated  solutions,  4he  unnecessary  addition  of  strong  anti- 
septics to  the  solution,  traumatism  during  the  operation,  spiculae  of 
bone  left  in  the  socket — all  these  may  also  be  considered  as  other 
contributing  causes  for  post-operative  pains. 

Another  unpleasant  sequelae  after  extraction  is  edema,  manifest- 
ing itself  by  a  more  or  less  pronounced  swelling. 

This  condition  may  be  caused  by  non-isotonic  solutions,  exerting 
osmotic  pressure  in  either  direction  between  the  tissue  cells  and  the 
injected  fluid  and  causing  death  of  the  cells,  as  explained  in  the 
chapter  dealing  with  the  j)reparation  of  the  solution.  Edema  may 
also  be  caused  by  injecting  into  a  muscle.  Anesthetic  solutions,  as  a 
rule,  are  absorbed  very  quickly  by  the  connective  or  areolar  tissues. 
The  absorption,  however,  is  very  slow  when  a  muscle  is  injected. 
In  the  mandibular  injection,  if  the  needle  is  inserted  too  low,  beneath 

Page    Twenty-nine 


the  lingula,  or  too  incsially.  the  Intenial  Pterygoid  imiscle  may  l)e 
infiltrated,  causing  edema  and  sometimes  false  ankylosis,  lasting  from 
a  few  hours  to  a  day  or  two. 

TREATMENT 

Post-operative  pains  may  be  abated  in  the  following  manner:  The 
socket  is  at  first  thoroughly  washed  out  with  warm  saline  solution. 
All  spiculae  of  bone,  if  any,  are  removed  and  the  socket  is  then 
packed  with  iodoform  gauze  saturated  with  Procaine  powder.  Or 
else  the  Procaine  powder  may  be  l)lown  into  the  painful  socket  by 
means  of  the  powder  blower,  after  which  it  is  gently  packed  with 
the  gauze.    The  following  mixture  ( Tribe! 's)  will  be  found  efficacious: 

Chloral-hydrate     2.0 

Camphor 1.0 

Procaine   0.5 

Internally,  Phenacetin  or  Aspirin  in  five-grain  doses  may  be 
administered,  to  be  repeated  again  in  three  hours,  if  necessary. 

TOXIC  EFFECTS 

With  the  introduction  of  Procaine  in  combination  with  Suprarenal 
Extract  in  local  anesthesia  the  toxic  effects  have  been  reduced  to  a 
minimum.  The  author  has  been  using  this  combination  for  more 
than  ten  years,  injecting  in  thousands  of  cases,  some  of  the  patients 
suffering  from  serious  cardiac  and  pulmonary  lesions,  and  has  yet 
failed  to  observe  manifestations  of  any  serious  toxic  symptoms. 

The  Suprarenal  Extract,  by  its  vaso-constriction,  prevents  the 
constitutional  absorption  of  the  injected  anesthetic,  thereby  still 
further  diminishing  its  toxicity. 

Any  anesthetic  should  l)e  injected  very  slowly  into  the  tissues. 
Experiments  upon  animals  have  proven  that  the  toxicity  is  increased 
with  the  rapidity  of  the  injection.  This  rule  holds  also  true  to 
Procaine. 

There  are  cases,  however,  when  toxic  symptoms,  although  rare, 
do  arise,  and  they  are  more  often  due  to  the  psychic  attitude  of  the 
patient  toward  the  impending  operation  than  to  the  actual  toxicity 
of  the  drug.  These  symptoms  may  manifest  themselves  by  simple 
pallor,  palpitation,  or  slight  trembling  of  the  extremities,  especially 
noticeable  in  anemic  patients.  These  symptoms,  as  a  rule,  disappear 
quickly,  by  the  administration  of  aromatic  spirits  of  ammonia,  or 
about  seven  or  eight  drops  of  camphorated  validol  in  a  little  water. 
Strong  black  coffee  is  also  very  efficacious  and  the  effect  very  lasting. 

In  more  dis(|uieting  symptoms,  such  as  fainting  or  syncope,  the 
head  should  be  lowered  to  increase  its  blood  supply.  This  should  be 
followed  by  the  inhalation  of  ether  or  from  one  to  tliree  drops  of 
erayl  nitrate  on  a  napkin. 

All  of  these  preparations  sbould  ])e  kept  always  on  hand,  ready 
for  immediate  use,  sbould  necessity  arise. 

Page   Thirty 


CHAPTER  VII 


PULP  EXTIRPATION   UNDER  LOCAL  ANESTHESIA 

Pulps  may  be  extirpated  painlessly  and  more  or  less  bloodlessly 
with  an  ordinary  infiltration  injection,  using  about  2  cc.  of  a  2^ 
Procaine  solution  for  each  pulp  to  be  anesthetized.  Two  Novol 
Procaine-Suprai'enal  Extract  Tablets  No.  1  (Dental)  are  dissolved 
in  2  cc.  of  Ringer  Solution  and  then  injected  above  the  apex  of  the 
tooth  from  which  the  pulp  is  to  be  removed,  II/2  cc.  on  the  buccal  or 
labial  side  and  the  remaining  I/2  cc.  on  the  lingual  side. 

The  technique  for  this  injection  is  the  same  as  described  under  the 
chapter  on  "Infiltration  Anesthesia.""  Extreme  precautions  should 
be  exercised  in  maintaining  strict  asepsis,  as  an  infection  nuiy  lead 
to  very  troublesome  pericemental  inflammation. 

After  the  injection  of  the  solution,  about  five  or  ten  minutes 
should  elapse  before  the  attempt  is  made  to  extirpate  the  pulp. 
This  interval  of  time  may  be  utilized  in  adjusting  the  rubber  dam 
to  the  tooth  to  be  operated  on  and  also  in  the  sterilization  and  pre- 
paration of  the  necessary  instruments. 

The  pulps  of  the  incisors,  cuspids,  bicuspids  and  quite  often  the 
upper  molar  teeth  may  be  efficaciously  removed  in  this  manner. 


EXTIRPATION    OF    PULPS   UNDER    CONDUCTION 
ANESTHESIA 

The  extirpation  of  pulps  under  conduction  anesthesia  is  not  as 
a  rule  uniformly  successful.  The  pulps  of  the  incisor  teeth,  when 
anesthetized  by  the  conductive  method,  may  still  be  sensitive  due 
to  the  anastomosis  from  tire  opposite  side.  In  these  cases  pressure 
anesthesia  should  be  used  to  completely  anesthetize  the  pulp. 

It  has  also  been  found  in  successful  mandibular  injections  that 
the  pulp  of  a  molar,  for  instance,  although  painlessly  exposed,  may 
yet  sometimes  be  sensitive  to  the  penetration  of  the  broach.  The 
anesthesia  here,  too,  may  be  completed  very  easily  by  the  pressure 
method,  using  a  Novol  Procaine  billet. 

Many  operators  have  great  success  in  extirpating  pulps  under 
conductive  anesthesia  by  using  a  3%  and  even  a  4%  Procaine  Solu- 
tion, dissolving  3  or  4  Novol  Procaine  Tablets  No.  1  (Dental)  to 
each  2  cc.  of  Ringer  Solution. 

The  anesthetization  of  the  pulps  of  the  lower  molar  teeth  by  the 
ordinary  infiltrative  method  is  seldom  successful  due  to  the  density  of 
the  alveolar  process. 

Page    Thirty-one 


Teeth  with  pulps  partially  calcified  and  also  teeth  with  pulp 
stones  will  resist  devitalization  by  arsenic  or  pressure  method.  Such 
teeth  should  only  be  devitalized  by  means  of  a  local  injection. 

CAVITY  PREPARATION 

In  cavity  preparation  conduction  anesthesia  may  be  used  with 
almost  uniform  success.  It  will  be  found  a  real  blessing  in  hypersen- 
sitive cavities.  The  technique  of  the  injections  is  the  same  as  outlined 
before,  with  the  exception  that  the  anterior  and  posterior  palatine 
injections  are  not  necessary  in  anesthetizing  the  upper  incisors, 
cuspid  and  molar  teeth,  and  also  the  long  buccal  (Buccinator  muscle) 
anesthesia  may  be  omitted  in  a  mandibular  injection. 

Care  should  be  taken,  however,  in  excavating  cavities  of  teeth 
which  have  been  desensitized  in  this  manner  not  to  penetrate  into 
the  pulp  chamber  and  thus  injure  the  pulp  tissue. 


BIBLIOGRAPHY 

Blum:     The  Technique  of   Conductive  Anesthesia,   Dental   Summary,    1915. 

Blum:     Mandibular    Anesthesia,    Dental    Cosmos,     1916. 

Blum:     Notes  on   Conductive   Anesthesia,    The  Journal  of  the   National  Dental 
Association,   1917. 

Gray's    Anatomy. 

Thoma:    Oral  Anesthesia. 

Fischer:     Local  Anesthesia  in  Deiitistiy. 

Smith:     Dental    Review,    191S. 


Page   Tliirty-t'vo 


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'e/^^^^r: 


(reg.  u.  s.  pat.  office) 

Procaine  Tablets 

UNDER  THE  PROVISIONS  QF  THE 
TRADING  WITH  THE  ENEMY  ACT 

The  U.  S.  Government  has  taken  over  the 
patent  that  gave  monopoly  for  the  manu- 
facture of  the  local  anesthetic,  Novocain,  to 
a  German  corporation,  and  has  granted  li- 
censes to  American  concerns  for  the  manu- 
facture of  this  product,  on  condition,  how- 
ever, that  this  drug  should  be  called  by  an 
American  name — Procaine,  and  that  it  shall 
be  made  in  every  way  as  the  article  originally 
imported  from  Germany. 

Samples  of  our  Procaine  have  been  submit- 
ted to  the  Federal  Trade  Commission,  which 
has  established  its  chemical  identity  and  pur- 
ity. 


NOVOCOL  CHEMICAL  MFG.  CO.,  inc. 


2923  ATLANTIC  AVE. 


BROOKLYN,  N.Y. 


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•■e/<^^«^ ; 


I  Procaine  Tablets 

j  are   offered    in   the    following   formulae,   with    and  | 

j  without  a  combination  of  Suprarenal   Extract.  | 

I  NO  vol.  PROCAINE  -  SUPRARENAL  EXTRACT  TABLETS  I 

I  "NO.  1"  (DENTAL)  | 

I  Procaine  )/]  grain  (0.02  gram).  I 

j  Suprarenal    Extract    1/1500    grains    (0.000045  j 

I  gram).  | 

I  1  tablet  dissolved  in  16  minims  (i  cc.)  of  physio-  f 

I  logical  salt  or  Ringer  solution  will  give  a  2%  | 

I  solution.  I 

j  1  tablet  dissolved  in  32  minims  (2  cc.)  of  physio-  | 

I  logical  salt  or  Ringer  solution  will  give  a  1%  | 

I  solution.  I 

I  Tubes  of  20,  55c.    Vials  of  100,  $2.50.  ! 

i  10  tubes,  $5.00.     6  Vials.  $13.50  I 

i  NOVOL  PROCAINE  -  SUPRARENAL  EXTRACT  TABLETS  f 

I  "NO.  2."  I 

I  Procaine  Ys  grain  (0.02  gram).  I 

I  Suprarenal     Extract     1/3300    grain     (0.00002  | 

j  gram).  | 

I  1  tablet  dissolved  in  16  minims  (1  cc.)  of  physio-  | 

I  logical  salt  or  Ringer  solution  will  give  a  2%  | 

I  solution.  I 

I  Tubes  of  20,  55c.    Vials  of  100,  $2.50.  I 

I  10  tubes,  $5.00.     6  Vials,  $13.50  I 

I  NOVOL  PROCAINE  -  SUPRARENAL  EXTRACT  TABLETS  I 

I  "NO.  3."  I 

I  Procaine  1.5  grain  (0.1  gram).  I 

I  Suprarenal     Extract     1/300    grain     (0.000225  | 

j  gram).  | 

I  1  tablet  dissolved  in  160  minims   ( 10  cc.)  of  phy-  | 

I  siological  salt  or  Ringer  solution  will  give  a  1%  | 

I  solution.  I 

I  1  tablet  dissolved    in  80  minims  (5  cc.)  physio-  | 

I  logical  salt  or  Ringer  solution  will  give  a  2%  | 

I  solution.                                               ^  I 

I  Tubes  of  10,  70c.            10  tubes      $6.30  I 

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HOW  TO  USE 


:e/^f^^2?: 


(Reg.  U.  S.  Patent  Office) 


Local  Anesthetic  with 
Suprarenal   Extract  Tablets 

In  Infiltration  and  Conduction  Anesthesia 


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1.  Fill  Porcelain  dissolve] 
oz.  of  Novol. 

NOVOL  Local  Anesthetic  is  prepared  under  th 
most  exacting   antiseptic   precautions   and  is   ab 
solutely  sterile  when  it  leaves  our  laboratories. 
NOVOL   has    the    most   ideal    combination. 
( 1  )    Procaine   (drug  introduced  by  the  German 
as  Novocain  ) — Seven  times  less   toxic  than  Cocaine 

(2)  Suprarenal  Extract — Localizes  and  intens; 
fies  the  action  of  the  anesthetic.  By  virtue  of  its  vase 
constriction  it  also  acts  at  the  same  time  as  a  cardia 
stimulant. 

(3)  Chloretone — A  safe  antiseptic,  mild  ane; 
ihetic  and  hypnotic. 

(4)  Ringer  Solution — Sodium  Chloride,  Calciui 
Chloride  and  Potassium  Chloride  (all  chemicall 
pure)  to  make  a  solution  of  the  same  density  an 
saline  strength  as  the  cell  contents  and  normal  bloo 
serum. 
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4.    Ready  for  injection. 

'  ROTECT  unused   portion   fronr  dust   and   light 
with  glass  cover  until  the  next  extraction. 

Enough    for   3   or  4   extractions. 


It  akes  but  a  minute  to  prepare  a  %  oz.  of 
lovcl  Local  Anesthetic  in  this  manner,  enough  per- 
aps  for  your  days  work. 

But  in  this  minute  you  have  done  everything  in 
3ur  power  to  protect  not  only  the  health  and  com- 
)rt  of  your  patient,  but  your  own  reputation. 


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THERE  are  other    methods  of  pre- 
paring Novol  Local  Anesthetic. 


Some  operators  prepare  only  enough  Novol  fo 
each  extraction  by  boihng  about  2>^  c  c.  of  Novol  ii 
a  Porcelain  Dissolving  dish  and  then  adding  3/2  o 
1/3  of  a  Suprarenal  Extract  Tablet. 

Others  boil  1  oz.  of  Novol  and  then  add  4  Sup 
rarenal  Extract  Tablets. 

And  still  others  prefer  to  boil  the  entire  conteni 
of  the  bottle  and  then  dissolve  all  the  tablets  at  on 
time. 

This  would  only  be  advisable,  however,  if  a 
or  4  oz.  bottle  of  Novol  may  be  used  up  in  con 
paratively  short  time. 

Novol  Local  Anesthetic  contains  1.5%  ol  Pr 
caine,  strong  enough  for  any  operation. 

A  stronger  Procaine  solution  may  be  easily  o 
tained,   if  nectssary.   by   the   addition  of  one  or  tv 
Novol  Procaine  Tablets  No.   1    (Dental)  to  each 
oz.  of  Novol  liquid  after  it  has  been  boiled. 


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1 

ACCESSORIES 

PRICE  LIST  No.  3 

NOVOL  Perfecto  Syringe  (glass  and  metal)  complete  with    all    attachments 
and  metal  box,  which  may  be  used  as  a  sterilizer.    $12.00 

NOVOL  Perfecto  Syringe  only  with  wrench  and  cap.                 _              6.50 

NOVOL  Stove  for  sterilizing  the  Novo!  Perfecto  Syringe 1.50 

NOVOL  All  metal  Syringe,  washerless,  ground  in  metal  plunger 3.00 

NOVOL  Conducto  Syringe,  all  glass  (Luer  type)  2cc 1.75 

NOVOL  Conducto  Syringe,  all  glass  (Luer  type)  3cc               .                2.25 

NOVOL  Ringer  flask,  with  ground  in  glass  stopper  and  cap 2.00 

NOVOL  Porcelain  dissolver  ^cc  with  slass  cover                                             .75 

NOVOL 

NOVOL    Platinum  needl 

25 

lOcc.  ' I.OO 

es                                                                                               1 

!mm.  23  gauge 3.00 

»mm.  25  gauge 2.00 

Novocol  Chemical  Mfg.  Co.,  Inc. 

2923  ATLANTIC  AVE.                         BROOKLYN,  N.  Y. 

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A:^*^!' 


Local  Anesthetic  with 
Suprarenal  Extract  Tablets  offers  a 
great  variety  of  uses 


np  HE    percentage  of  Suprarenal   Extract  may  be 
increased  or  diminished  as  necessity  dictates. 

Should  the  operator  desire  a  stronger  anesthesia, 
a  more  bloodless  operation,  two  instead  of  one  Supra- 
renal Extract  Tablets  may  be  used  to  each  ^  oz.  of 
Novol. 

On  the  other  hand,  there  are  certain  cases  when 
less  Suprarenal  Extract  is  desirable,  which  can  be 
easily  done  by  using  only  ^^  a  Suprarenal  Extract 
Tablet  to  each  34  oz.  of  Novol. 

The  Suprarenal  Extract  Tablets  are  very  effective 
in  checking  hemorrhage  after  extractions. 

The  procedure  is  simple.  Wash  out  the  bleed- 
ing socket  with  hot  water.  Place  one  Suprarenal 
Extract   Tablet   in   the   socket,    and   apply   pressure. 


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'•You  Make  a  Mix" 

of  oxyphosphate  of  zinc  cement  for  every  operation, 
whether  it  is  of  a  temporary  nature  or  for  the  cemen- 
tation of  an  inlay  or  a  bridge. 

Yet  the  after  effects  of  an  extraction  may  be 
much  more  serious  than  that  of  an  improperly  set 
bridge. 

Truly,  is  it  not  worth  while  to  take  just  one 
minute  of  your  time  and  be  certain  that  no  infection 
or  perhaps  death  will   follow  an  extraction? 

PRICES 

2  oz,  bottle      .....$    1.10 

4  oz.   bottle 2.00 

24  oz    (6-4  oz.)  .       .       .        11.50 

48  oz.  (12-4oz.)        .      .      .       22.50 

3  c  c.    Novel  Porcelain  Dissolver   (to  boil 
14    oz.    Novol)  75c. 

10  C.C.  Novol  Porcelain  Dissolver  (to  boil 

y^  oz.  Novol)       .     .     .      $1.00 

FOR   SALE   BY 

NOVOCOL  CHEMICAL  MFG.  CO.,  Inc. 

2923  Atlantic  Ave. 

Brooklyn,  N.  Y. 


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1  NOVOL  PROCAINE  TABLETS  "NO.  4."  | 

I  Procaine  ^  grain  (0.05  gram).  | 

I  1  tablet  dissolved  in  40  minims  (2.5  cc.)  of  p,h^'        | 

1  siological  salt  or  Ringer  solution  will  give  a  ^'  | 

I  solution.  I 

I  Tubes  of  20,  55c.  | 

I  10  tubes  $5.00  | 

I  NOVOL  PRESSURE-STHESIA  BILLETS  | 

I  For  Pressure  Anesthesia.  | 

I  Procaine  0.01  gram.  | 

I  Suprarenal  Extract  0.00015  gram.  j 

I  Tubes  of  20,  50c.    Vials  of  100,  $2.25.  | 

I  10  tubes,  $4.50        6  Vials,  $12.50.  | 

I  RINGER  TABLETS.  | 

I  Each  tablet  contains  | 

I  Sodium  Chloride             0.05     gram.  | 

I  Potassium  Chloride        0.002  gram.  | 

|.  Calcium  Chloride           0.004  gram.  | 

I  Tubes  of  20,  10c.    Vials  of  100,  40c.  | 

i  To  make  a  Ringer  solution  dissolve  three  tablets       | 

I  to  an  ounce  of  distilled  water.  j 

I  PROCAINE  POWDER  | 

I  5  gram  vials,  $2.00  per  vial.  j 

I  1  oz.  containers,  $8.50  per  oz.  | 

I  NOVOL  PORCELAIN  DISSOLVER  | 

I  3  cc,  75c.  j 

I  10  cc,  $1.00  I 

I  NOVOCOL  CHEMICAL  MFG.  CO.  | 

j  2923  Atlantic  Ave.                              Brooklyn,  N.Y.       | 

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I                             DIRECTIONS  I 

I  '^'The  technic  of  the  use  of  Novel  Procaine  Tablets  is  very  simple.  | 

I             A  stock  of  physiological  salt  or  Ringer  solution  is  kept  on  hand.  | 

I  These  are  easily  prepared  by  dissolving  3  grains  of  salt  or  3  Ringer  | 

I  Tablets  to  an  ounce  of  boiled  distilled  water.     About  2^  cc.  of  | 

I  this  physiological  salt  or  Ringer  solution  is  placed  in  a  Novol  For-  | 

I  celain  dissolving  dish  and  the  contents  boiled  over  an  alcohol  flame.  | 

I  Two  Novol  Procaine  Suprarenal  Extract  Tablets  are  added  and  the  | 

I  solution  again  brought  to  the  boiling  poin*-  for  but  a  few  seconds  | 

I  and  the  solution  is  then  ready  for  injection.  | 

I                  Caution: — Do  not  prolong  the  boiling  after  the  Novol  Pro-  | 

I  caine  Suprarenal  Extract  Tablets     have  been   added.       This  does  | 

I  not,  however,  apply  to  the  Novol  Procaine  Tablets  No.  4,  which  | 

I  may  be  boiled  without  fear  of  decomposition,  as  they  do  not  contain  | 

I  Suprarenal  Extract.  | 

I              The   Ringer    solution   must   be    neutral   in  reaction  as   the   slightest  | 

I  alkalinity  will  turn  the  Suprarenal   Extract   at   first   a   pinkish   and   then  | 

I  brownish  color,  when  the  Novol  Procaine  Suprarenal  Extract  Tablets  are  | 

1  dissolved  in  the  porcelain  dish.  | 

I              To   obviate  this  difficulty  the   following   simple   expedient   may    be  | 

I  adopted:  I 

I              Dissolve  1  0  drops  of  dilute  hydrochloric   acid  in  one  ounce  of  distilled  | 

I  water.    This  should   always   be   kept   on   hand.    When   making   up    a  | 

I  Ringer  solution,  add  one  drop  of  this  2%  H  C  L  to  each  ounce  of  the  | 

I  Ringer  solution.  = 

I              Strict  asepsis  must  be  maintained  before,  during  and  after  the  | 

I  operation,  such   as  sterilizing  the  needle  and  syringe,  etc.     The  | 

I  field  of  operation  should  be  painted  with  equal  parts  of  aconite  and  | 

i  iodine.  1 


lllllllll'llllllllllllllMIIIIIIIIMIIIIIIIIMIIIIMIIIIIIIIIIIIIIIIItHllllllllllllllllimilllllirR 


;"e/^^;^^r: 


FOR 

CONDUCTION 
INFILTRATION 

AND 

PRESSURE 
ANESTHESIA 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  ai  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge.                                     1 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28(e38)ME0 

I.K510 


N411 
1919 


Conduction  &nd  inf iltrf ti-n 


^\(^}^ 


l9J9 


COLUMBIA  UNIVERSITY  LIBRARIES  I hs    ■ 

RK510N411  1919  C.1 

Conduction  and  infiltration  anesthesia  w 


lllllllllllll 
2002397358 


